Fillable Advice Request Form Is this case an Emergency?

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Advice Request Form Is this case an Emergency?

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UCD Veterinary Hospital, UCDVH
Ospidéal Tréidliachta UCD
Hub: 01 716 6200 Email: vethub@ucd.ie
Advice Request Form
Please complete this form and email to
vethub@ucd.ie along with the clinical
notes, diagnostic reports and images.
Internal Medicine
Neuro
– Medical
Surgery – Neuro
Dermatology
Oncology
WoundMgmt.
Cardiology
Surgery –Ortho
Rehab / PT
Endocrinology
Surgery - Soft Tissue
Pain Clinic /Acupuncture
Main Query: please remember to attached clinical notes, images laboratory reports, videos/photos is available
Laboratory results
Imaging Photo/videos
Treatment/Current Medication:
Attachments:
Clinical notes
Email address:
Primary Vet:
Practice name:
Vet Address:
Main number:
Client name:
Breed:
Animal name: Species: Colour:
Age:
Weight:
Is this case an Emergency? YES NO
If so please also call 01716200 to bring it to our attention
Please note there is a 30 euro charge for advice . If radiographs are included there maybe an additional
30 euro DI interpretation charge. This charge will be credited if the animal is referred to the Hospital.
Advice
requested:
SEX
Insured?
Additional Information:
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Advice Request Form Is this case an Emergency

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Completed 10 November 2021

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